The nursing care priorities for the patient with burn injuries include wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is most likely in which phase of burn care?
Rehabilitative
Acute
Emergent
Immediate resuscitative
The Correct Answer is B
Choice A reason: The rehabilitative phase of burn care focuses on restoring function, improving cosmetic appearance, and achieving the best possible quality of life for the patient. This phase typically begins after the wound has healed and continues for months to years. The care priorities mentioned, such as wound care and nutritional support, indicate that the patient is still in a more active phase of treatment rather than the long-term rehabilitative phase.
Choice B reason: The acute phase of burn care starts after the initial resuscitation and continues until the wound is closed. During this phase, the primary focus is on wound care, nutritional support, and prevention of complications like infection. The goal is to promote healing, prevent infection, and address the patient's nutritional needs to support recovery. This phase aligns with the care priorities mentioned in the question.
Choice C reason: The emergent phase, also known as the resuscitative phase, begins at the time of injury and continues for the first 24-48 hours. The primary focus during this phase is on stabilizing the patient's condition, managing airway and breathing, fluid resuscitation, and addressing immediate life-threatening issues. The care priorities in the question indicate that the patient has moved beyond the initial resuscitative efforts.
Choice D reason: The immediate resuscitative phase overlaps with the emergent phase and focuses on providing immediate life-saving measures to stabilize the patient. This includes fluid resuscitation, airway management, and treating shock. The care priorities mentioned in the question suggest that the patient is beyond the initial resuscitative efforts and is in a more ongoing phase of treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Inotropic drugs are used to improve the strength of the heart's contractions and support cardiac output in cases of heart failure or cardiogenic shock. While they may be used as supportive therapy in septic shock to maintain blood pressure and perfusion, they are not the primary treatment.
Choice B reason: Antibiotics are the primary and most crucial therapy for managing septic shock. Septic shock is caused by a severe infection that leads to systemic inflammation and organ dysfunction. Prompt administration of broad-spectrum antibiotics is essential to target the underlying infection and prevent the progression of septic shock. Antibiotic therapy is initiated as soon as possible, often after obtaining blood cultures to identify the causative pathogen.
Choice C reason: Antidysrhythmic drugs are used to manage abnormal heart rhythms, such as atrial fibrillation or ventricular tachycardia. They are not specific to the treatment of septic shock but may be used if the patient develops arrhythmias as a complication of the shock state.
Choice D reason: Beta blockers are used to manage hypertension and certain types of arrhythmias by reducing the heart rate and the workload on the heart. They are not typically used in the acute management of septic shock and may even be contraindicated due to their potential to decrease cardiac output.
Correct Answer is A
Explanation
Choice A reason: An increase in serum hematocrit indicates that epoetin has been effective. Epoetin, also known as erythropoietin, is a medication used to stimulate the production of red blood cells. In patients with chronic kidney disease, the kidneys may not produce enough natural erythropoietin, leading to anemia. By administering epoetin, the goal is to increase red blood cell production, which is reflected in higher hematocrit levels (the proportion of red blood cells in the blood).
Choice B reason: An increase in serum calcium is not related to the effectiveness of epoetin. Serum calcium levels are regulated by different mechanisms, including parathyroid hormone and vitamin D, and are not directly influenced by epoetin administration.
Choice C reason: A decrease in serum creatinine levels would indicate improved kidney function, but this is not the expected outcome of epoetin therapy. Epoetin specifically targets red blood cell production and does not have a direct impact on kidney function or creatinine levels.
Choice D reason: A decrease in blood pressure is also not an expected indicator of epoetin effectiveness. While managing blood pressure is important in chronic kidney disease, epoetin's primary role is to address anemia by stimulating red blood cell production. Blood pressure regulation involves other medications and interventions.
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